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4-25-202 4:0l PM FROt '-ARK WELL. 09462SS97 P•2 <br /> �- INC-_ - FILE COPY <br /> WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY UNIT IV <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 11 YEAR FROM DATE ISSUED <br /> Apprication is hereby made to San Joaquin County for a permit to construct and/or install the work described, This application is made in compliance with San <br /> Joaquin County Development Title,Chapter 41115.3 and the Standard.of San Joaquin County Environm ntal Health Department. <br /> Assessor's <br /> WELL location 869 0 LI tJN e?0- cross street>: City <br /> PROPERTY Owner Triple E Address_8690 Linne Rd_City Tracy_Zip Phone# <br /> CS7 Contractor_Ciark W 1,Inc_ Address 2024 East Charter Wav City Stockton— Zip95205 Lic# 371560_ Phone#(209)462 7676_ _ <br /> Gonsulfa !Sub Cnt dress �` LiC# 21//3 5phone#71i2 �J <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> p NEW WELL/BORING(CPT.GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER") DQ DESTRUCTION(choose type below) <br /> []SOIL BORING# Q OVER-BORE <br /> 0 WELL# RESSURE GROUT <br /> 'Other:, Grout Specift 2tions:_9 sack sand <br /> COMMENTS <br /> jV <br /> TYPE OF{HELI INSTALLATION TYP_E_. CONSTRUCTION SPECIFICATIONS <br /> a MONITORING U HOLLOW STEM DIA,OF BOREHOLE MULTIPLE CASINGS?BYES I]NO WELL CASING DIA; <br /> I]EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: []STEEL Q PVC Q OTHER: <br /> q VAPOR U MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: []AUGERS Q HOSE <br /> Q AIR SPARGE Q PUSH POINT GROUT SEAL PUMPED: Q Yes Q No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30) <br /> Q SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS: <br /> I]OTHER: fl OTHER APPROX.BORING DEPTH Q BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> CONDUCTOR CASING PR OSED? (if YES,list specifications here); <br /> *COMMENTS: f e <br /> �G<-e <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. .� <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, ule Re lations,and all applicable California State Laws. <br /> Signed x Trtle/Company_Clark Well,Inc <br /> Print NameMichael R.Clark Date�3 April 2002_ <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 8620 t!/ T <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued__ ` 21 <br /> Groui Inspection By ate_Final Inspection By <br /> Destruction Inspection By Date <br /> COMMENTS f CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMIT TED CHECK# REC'D BY] DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 90 y t�J� b0 3225 ? SR# OOZ 3 <br /> /' F7 %A//' kA/ATQCD r R7 1 ..++..« ..f A..+L...«i+-+:.,.. 4-- n:..«.+..«...:+ C«-«....----«+ A— 1/7RIog <br />